Safety of Discharge of Seniors from the Emergency Department to the Community

Abstract

This study investigated the safety of discharge of seniors (aged 65 and over) from Quebec emergency departments (EDs) to the community. Data from a 2006 survey of key informants at 103 Quebec adult non-psychiatric EDs were linked to data on a sample of 172,927 seniors who were discharged home from one of the EDs during the period February 2004-January 2005. During the 30 days after the ED visit, 1.0% of patients died, 5.0% returned to the ED and were admitted to hospital, 16.0% returned to the ED but were not admitted and 29.2% were prescribed a potentially inappropriate medication. Larger, urban EDs treated a higher-risk patient population (older, greater co-morbidity), and these seniors had worse outcomes. A minority of EDs, regardless of their size and the characteristics of patients treated, systematically provided services to improve the safety of discharge. Resources and services need to be improved in EDs, particularly those that serve higher-risk populations (e.g., systematic approaches to the identification and management of high-risk seniors, with appropriate referrals to community services), in the hospital (e.g., increased accessibility to acute care beds) and in the community (e.g., increased accessibility to home care, outpatient geriatric assessment and primary medical care).

Background

Although there have been numerous studies of patient safety in
the hospital setting, little research has focused on the emergency
department (ED). The ED, a critical interface between the hospital
and community, presents major challenges to patient safety that are
of particular importance in the rapidly growing population of
seniors (defined here as those aged 65 and over). Higher levels of
co-morbidity, physical and cognitive impairment and polypharmacy
make seniors particularly vulnerable to adverse outcomes after an
ED visit, such as functional decline, mortality and early return ED
visits (McCusker et al. 1999). In addition, the busy ED environment
promotes a focus on rapid treatment and disposition of patients. A
failure to detect problems that require investigation or
intervention, such as delirium or medical conditions that may have
contributed to a fall, may result in discharge without appropriate
referral for assessment and lead to increased rates of return
visits and other adverse outcomes (Hohl et al. 2001; Kakuma et al.
2003; McCusker et al. 1999, 2000a, 2000b). A failure to review
patient medications may increase adverse effects resulting from
polypharmacy and inappropriate prescribing (Beers et al. 1990; Hohl
et al. 2001). Limited access to patient information from the
primary physician, home care services, previous hospitalization or
previous ED visits, for example, may lead to inappropriate
treatment and disposition (Stiell et al. 2003). Finally, a failure
of ED staff to transmit information about the visit to the primary
physician and to community services (e.g., home care) may result in
delays before the patient is eventually reassessed, treated or
provided services (McCusker et al. 2001).

In light of these challenges, safer discharge of seniors from
the ED may involve improvements in services and staff to assess the
patient needs, detect geriatric problems, review and modify
medications, access community services and transfer appropriate
information to family physicians. Thus, this study aimed to
describe (1) the services provided to seniors in different types of
EDs, (2) the profiles of seniors who are discharged home from
different types of EDs and (3) the outcomes of these seniors during
the 30 days after an ED visit.

Methods

Study Design and Sample

This study linked data from ED registries, physician billings,
hospital discharges and a survey of key informants. The study
protocol was approved by the Commission d'accès à l'information and
the Research Ethics Committee of St. Mary's Hospital.

ED Registry Data

Provincial ED registry data were used to compute the volume of
visits, the number of ED beds (stretchers), the daily average
length of stay on ED beds and a measure of crowding - the average
daily ratio of patients to ED beds. Because these data cannot be
linked at the patient level to other administrative databases, we
identified individual patient ED visits from the administrative
databases described below.

Provincial Administrative Databases

Three linked provincial administrative databases (hospital
discharge [MedEcho], physician billing and medication prescription
[Régie de l'assurance maladie du Québec; RAMQ] databases) for the
Quebec population were used to describe patient characteristics,
index ED visits and outcomes. ED visits were identified in the RAMQ
database using a validated method (Dendukuri et al. 2005). The
index ED visit was defined as the first visit during the 12-month
study period of February 2004 to January 2005. The study sample was
composed of 172,927 non-institutionalized patients aged 65 or over
who had an index ED visit during the 12-month period to one of 103
Quebec adult, non-psychiatric EDs and were discharged home. Figure
1 illustrates how the sample was derived.

Survey of Key Informants

A survey was conducted during the summer of 2006 using
questionnaires directed to the ED chief physician and head nurse.
If there was an individual responsible for the care of seniors,
this person assisted the head nurse with the relevant sections of
the questionnaire. Response rates were 71% for physicians and 90%
for nurses. Head nurses were queried on the following: nurse
staffing per shift, non-medical professionals involved in ED care
of seniors, ED geriatrics services (the use of standardized
screening and assessment tools, a discharge planning protocol,
post-ED telephone follow-up) and satisfaction with home care
services. Chief physicians were queried on medical ED staffing
(number of physicians per weekday shift), the availability of
geriatrics and psychogeriatrics consultation, whether there is a
pharmacist or pharmacy technician in the ED, computerization and
the transfer of information to and from family physicians.

ED Classification

Other data on ED characteristics (location, university
affiliation, number of beds and level of care classified as
primary, secondary and tertiary based on comprehensiveness of
resources) were obtained from the Quebec Ministry of Health and
Social Services. An ED classification was developed based on the
following correlated ED characteristics: location, university
affiliation, number of beds and level of care. (Further details on
the methodology used to develop this classification are available
from the authors.) Three ED types were identified: (1) large EDs,
mostly with 21 or more ED beds and located mainly in the Montreal
area (n = 30); (2) medium-size EDs, mostly with 14-20 ED
beds and located mainly in urban areas outside Montreal (n =
29); and (3) small EDs, often based in health centres rather than
hospitals, most with fewer than 14 ED beds and located in rural
areas (n = 44) (Table 1).

Results

Table 1 shows selected characteristics of the three ED types,
including the variables used to create the classification. The mean
length of stay for patients on ED beds was 24 hours or more among
one in five EDs, with no significant difference by ED size. There
were significantly higher rates of crowding at larger EDs.

Services Provided by Different Types of ED

In general, the staff, resources and clinical tools of interest
were available in only a minority of EDs (Table 2); there were,
nevertheless, important differences by ED type. The ratio of
physicians to ED beds was lower at larger EDs. Some resources and
tools were significantly more available at larger EDs, such as
on-site pharmacy staff, a team leader for geriatric care,
geriatrics consultation, systematic screening and administrative
and clinical software. Community linkages with the family doctor
and home care services also differed by ED size - in smaller EDs,
there were higher rates of satisfaction with home care and of the
transmission of information from the ED to the family doctor.

Patient Profiles by ED Type

Patient characteristics indicated a population with high rates
of hospitalization and physician visits in the previous year (mean
of 2.5 days and 9.2 visits, respectively). There were significant
differences by ED type in many patient characteristics, most of
which showed a gradient across the type of ED (Table 3). (It should
be noted that even small clinical differences in patient variables
may be statistically significant because of the large sample size.)
Seniors discharged home from larger EDs were older, were more often
female, had higher co-morbidity scores and had higher rates of
hospitalization and physician visits in the previous year.

Patient Outcomes

Table 4 shows the frequency of 30-day outcomes and measures of
the process of care among seniors discharged home from the three
types of ED. The most serious outcomes - death (1.0%), and/or
return to the ED with hospital admission (5.0%), were found in 5.6%
of the sample (some patients experienced both outcomes). A further
16.0% made an ED return visit but were not admitted. Approximately
three of 10 seniors filled a prescription for a potentially
inappropriate medication, and the same proportion visited their
primary physician.

Table 4. Patient 30-day outcomes and process of care by ED
type

Type

Outcome

Total(N = 172,927) %

Large(n = 79,880) %

Medium(n = 49,540) %

Small(n = 43,507) %

Death

1.0

1.2

1.2

0.6

Return to ED with
hospital admission

5.0

5.5

5.0

4.0

Return to ED without
hospital admission

16.0

14.5

15.0

20.0

Potentially
inappropriate medication prescription

29.2

29.2

30.1

28.0

Primary physician
visit

32.0

33.4

31.7

29.8

ED = emergency department.

Even after controlling statistically for the patient
characteristics shown in Table 3, there were significant
differences in outcomes among the three types of ED (data not
shown): seniors who made an index visit at a large or medium ED
were significantly more likely than those visiting a small ED to
die or be admitted to hospital; in contrast, they were less likely
to make a return ED visit without hospitalization. ED type was not
related to visits to the primary physician or to the prescription
of a potentially inappropriate medication.

Discussion

This study represents a first step toward the assessment of the
safety of discharge of seniors from the ED, an important topic that
has received relatively little attention in the research
literature. It should be noted that the study was conducted in
Quebec, where ED stays of over 24 hours or even several days are
not unusual, particularly in the Montreal area. The study provides
a portrait of different types of Quebec EDs - large, medium and
small - and shows great variation in both the staffing and services
provided and in the seniors who were discharged home from different
types of ED.

The study results highlight some potential safety concerns for
seniors discharged to the community. Although the largest EDs
treated the oldest seniors with higher rates of co-morbidity,
hospitalization and doctor visits, their average length of stay for
seniors on beds was similar to that in smaller EDs. This suggests a
greater difficulty in accessing in-patient beds in the largest EDs,
with resulting higher rates of crowding (McCusker et al. 2007),
which has been linked to reduced quality of care, increased rates
of return ED visits and mortality (McCusker et al. 2007; Richardson
2006; Sprivulis et al. 2006). Other safety concerns in larger EDs
are the lower physician staffing ratios and the perceived lack of
availability of home care services.

Overall, only a minority of EDs offered the types of services
that can improve the safety of discharge of seniors to the
community, such as systematic patient assessment and discharge
planning (Hastings and Heflin 2005). Even among large EDs serving
higher-risk seniors, only about half did any systematic geriatric
screening, about one third used standardized tools to assess
patient function or cognition, 12% had a discharge planning
protocol and 40% usually sent patient information to the family
doctor. A standardized assessment of seniors while in the ED, along
with the transfer of key information to the family physician and
links to community services, is cost-effective because it both
reduces further functional decline and increases continuity of care
(McCusker et al. 2003a, 2003b). The implementation of such
approaches needs to be prioritized in the context of a rapidly
aging population.

Seniors discharged home from larger EDs tended to be somewhat
more severely ill and to include a higher proportion of high-risk
or frail elderly patients; these individuals likely required
substantially more medical and support services in the community.
Rates of death (1.0%) and total return ED visits with and without
hospital admission (21.0%) during the 30 days after the index visit
were within the range of those previously reported (Caplan et al.
2004; Lowenstein et al. 1986; McCusker et al. 2007; Mion et al.
2003; Ross et al. 2003); however, these outcomes differed by type
of ED. Seniors discharged from large or medium EDs had higher rates
of more severe 30-day outcomes (death or hospitalization), which
was consistent with their poor clinical status. In contrast, return
visits without hospital admission were more frequent in small,
rural EDs. There are several possible reasons for this occurrence.
Rural physicians often practise in multiple settings, including the
ED, and may conduct patient follow-up in the ED (Haggerty et al.
2007). Return ED visits may reflect inadequate treatment at the
initial visit. In addition, a small proportion may be planned
visits to follow-up on treatment, especially in smaller EDs where
other locations for follow-up may be less available.

Only 32% of patients visited their primary physician during the
30 days after being released home from an ED. This proportion
appears low and may reflect the use of the ED as a substitute for
primary care, a lack of accessibility to a primary physician or a
lack of communication between the ED and the primary physician
(McCusker et al. 2003a). An ED visit is a sentinel event for
seniors, and a routine follow-up visit to a family physician may
prevent a return ED visit (Caplan et al. 2004).

Limitations

Several limitations of this study should be noted. First, the
aims of the study were descriptive; further research needs to
examine the links between patient characteristics, services and
outcomes. Second, data on patient characteristics and outcomes were
derived from administrative databases, which contain limited data
of uncertain validity (e.g., diagnostic data). Third, ED registry
data have important limitations: they are not currently linked at
the patient level to other administrative databases, and data on
length of stay and crowding were not available for some smaller EDs
that either have few beds or do not report these data consistently.
Fourth, the survey data on the availability of specific services at
each ED did not indicate which of these services were actually used
or whether they were used for high-risk patients. Fifth, it was not
possible to distinguish between planned and unplanned return ED
visits. Sixth, it was not possible to determine which medication
prescriptions were given to patients at the ED visit because the
location of the prescribing physician was not available. Further
research could focus on changes in prescriptions from before to
after the ED visit to identify which medications were discontinued
and which were initiated. Finally, these data from Quebec may not
be generalizable to other provinces or countries.

Conclusion and Recommendations

The results of this study confirm that seniors are a high-risk
population whose needs may not be adequately addressed by existing
ED and community services (McCusker et al. 1999). While some of the
safety concerns identified in this study may require a redeployment
of governmental resources to those EDs, hospitals and communities
with higher-risk patients and the most severe ED crowding, other
concerns can be addressed within the ED by reorganizing existing
resources and implementing protocols (e.g., for the systematic
identification of seniors at risk and appropriate discharge
planning). Below we present improvements that can be done in the ED
itself, the hospital and the community.

Improvements in the Emergency Department

In the ED, a basic requirement is appropriate staffing. Ideally,
all EDs should have access to geriatrics nurses, teams or
consultants. In small EDs where it is not feasible to have
dedicated geriatrics staff, existing staff could be trained in
geriatrics, and referral networks could be developed.
Evidence-based services that could be implemented by a liaison
nurse or social worker include standardized, systematic ED-based
screening, assessment and discharge planning, with referrals as
needed for community services (Hastings and Heflin 2005; Verdon and
McCusker 2005; Warburton et al. 2004). High-risk seniors need more
complex discharge planning. A standardized approach, using
protocols, should be followed in all EDs. An increased involvement
of pharmacists in the ED or the use of software designed to
identify inappropriate medications may help to reduce
medication-related adverse events and return ED visits (Bizovi et
al. 2002; Forster et al. 2004; Langdorf et al. 2000). The length of
ED stays should be limited - longer stays may be particularly
detrimental for seniors. EDs should monitor their return visits to
determine whether they may have been prevented with better
management at the initial visit. Most importantly, regional health
planners need to recognize the differences between different types
of EDs. The case-mix of EDs should be measured, taking into account
not only age but level of illness and functional status; in this
manner, resources could be matched to the needs of the
patients.

Improvements in the Hospital

In the hospital, rapid accessibility to acute care beds is
needed, particularly in those larger EDs that suffer from high
rates of crowding. An increased availability of acute care beds or
innovative solutions for the use of these beds in large urban
hospitals (e.g., establishing a short stay unit for seniors) may
help to accommodate the increased need and reduce the adverse
outcomes associated with overcrowding (Forster et al. 2003).
Channels of transfer from the ED to subacute care, rehabilitation
or convalescent centres could be developed for appropriate
patients.

Improvements in the Community

At-risk seniors require follow-up in the community. It must
therefore be a priority to ensure that they have access to
essential community services (e.g., home care, geriatric
assessment, primary medical care) and experience continuity of care
(Ionescu-Ittu et al. 2007). This is of particular concern in Quebec
where the availability of family physicians is worse than that in
other Canadian provinces (Canadian Institute of Health Information
2005; Sanmartin 2006). Programs are needed to allow rapid home
assessment and routine follow-up visits to the family doctor. This
will require standardized communication between the EDs and the
community, appropriate funding of these resources and an adequate
supply of family doctors to take on new patients. Improvements in
the organization of community-based care for seniors with chronic
illnesses and the development of a continuum of care between
primary and secondary levels of care may also help to reduce ED
visits (Castonguay et al. 2008; Clair 2000). Such improvements in
access to services and continuity of care will augment patient
safety in this high-risk population.

About the Author

Jane McCusker, MD, DrPH, heads the Department of Clinical Epidemiology and Community Studies at St. Mary's Hospital in Montreal and is Professor in the Department of Epidemiology, Biostatistics and Occupational Health at McGill University.

Danièle Roberge, PhD, is an adjunct professor at the Université de Sherbrooke and her research is focused on the organization of emergency rooms, primary care and cancer care.

Alain Vadeboncoeur, MD, is a specialist in emergency medicine and Chief of the Medical Emergency Service, Montreal Heart Institute, member of the Montreal Heart Institute Research Centre and also a clinical associate professor, medical emergency division, department of family and emergency medicine, Université de Montreal.

Josée Verdon, MD, is a specialist in internal medicine and geriatrics at McGill University Health Centre, Royal Victoria Hospital and also an assistant professor, McGill University, Department of Medicine, Division of Geriatrics. Her areas of interest are based on care of seniors in the emergency room, interdisciplinary team approach, and models and process of care.

Warburton, R.N., B. Parke, W. Church and J. McCusker. 2004. "Identification of Seniors at Risk: Process Evaluation of a Screening and Referral Program for Patients Aged 75 and Over in a Community Hospital Emergency Department." International Journal of Health Care Quality Assurance 17(6): 339-48.